Tubal Reversal Blog ‘elective surgery’

Submitted by Dr. Monteith
Chapel Hill Tubal Reversal Center

Many doctors will give you less than a warm response when you ask about tubal ligation reversal. Ever wonder why?

I would like to use myself as an example. I started my obstetrics and gynecology (ob/gyn) residency in July 1997 and finished in June 2001. I never saw a single tubal reversal operation performed at the university where I trained. Not one. I saw many unusual and rare things, but I never saw a tubal ligation reversal. I am not alone. Many other doctors would probably tell you the same thing if you asked them.

Lack of Familiarity or Training

Most doctors- especially those who have trained within the last 15 years – are unfamiliar with tubal ligation reversal. The reason is simple. Ligation reversal is considered elective surgery. As a result, these procedures are rarely done in hospitals. Therefore, doctors in training get little or no exposure to these surgical procedures. Because of this, most doctors have little knowledge about these types of operations.

Sometimes doctors in training will reason that if they never saw a particular operation, the surgery does not exist because it is not beneficial and may even be harmful. Of course, this is faulty reasoning.

I would have never thought ligation reversal is an effective surgery if it were not for a three minute experience I had when I was a second year resident doing my reproductive endocrinology rotation.

I was with a physician who was the head of our reproductive endocrinology department. We were counseling a 38-year-old patient who was married, had a tubal ligation and wanted to become pregnant again. At the conclusion of her visit, she had asked what she should do? Since I had seen every patient with fallopian tube problems treated with in-vitro fertilization (IVF), I mumbled to myself, “We are going to recommend you get IVF.” Before I could finish my mumbled response, the director said, “I recommend you get a tubal ligation reversal.” My mouth dropped open! Why did we recommend an operation that we did not perform and one I had never seen? I remember exactly what he said next, “We can do this procedure for you. The cost of tubal reversal will be $15,000 here at the hospital. I recommend you talk with Dr. Gary Berger, a tubal reversal specialist who does them for considerably less cost.”

After the conversation, I asked him why we didn’t do tubal reversal procedures at our hospital. He responded, “Charles, we have to charge patients more for this surgery in the hospital. Since patients have to pay out of pocket, most people will be unable to afford the surgery with us. This is a great procedure for her because she will have the ability to get pregnant many times.”

“But isn’t the success rate less than 50 percent?”, I asked. He dropped his glasses down, looked over the rims and told me in a very direct voice, “No! In the best of hands, the success rate is 80 percent.” Somehow he seemed offended that I thought he had recommended a bad treatment.

This conversation happened in 1998. I filed this brief exchange in my memory and mostly forgot about it for the rest of my training.

Other Mistaken Ideas Doctors May Have

Many doctors might say a general ob/gyn resident would not see any of these surgeries while training, but a doctor in training as a reproductive endocrinologist would. Unfortunately, this is not true. I had two friends who trained to be reproductive endocrinology specialists. One did two tubal reversals over a three year period of training, the other did none.

It is unfortunate that my friends, who had little or no experience with reversal surgery, are going to be the same doctors who will counsel patients about it. No wonder they routinely recommend IVF – a treatment that they received almost exclusive training in during their fellowship programs.

Why I Came to Chapel Hill Tubal Reversal Center

I hope my personal experience can illustrate why general ob/gyn doctors may not support their patients who want to have their tubal ligations reversed, and why reproductive specialists mostly do IVF. I view tubal ligation reversal as a disappearing surgical skill that may not be available to patients in the future. This is why I asked to join Dr. Berger’s staff at Chapel Hill Tubal Reversal Center. To help women with tubal ligations who want to get pregnant is the reason why I have decided to embark on the path to become a tubal ligation reversal specialist.

In a recent email inquiry, someone asked if it would be safer to have tubal reversal surgery in a hospital. My response – “It is much safer to have tubal reversal surgery performed at Chapel Hill Tubal Reversal Center than in a hospital.”

Infection and Medication Error Risks in Hospitals

Roughly 100,000 people wind up with a potentially deadly infection during hospital treatment in the US each year, according to the Centers for Disease Control. Hospital-acquired infections (also called “nosocomial” infections) are particularly dangerous, since hospital germs are especially resistant to antibiotics. One example in the news recently is the bacteria called methicillin-resistant staphylococcus aureus (MRSA). Most of these dangerous bacteria are transmitted by hospital staff from other patients. In addition, hospital patients get the wrong drug one time out of five, according to a study by Auburn University.

Patient-safety incidents continue to rise in American hospitals. The largest increases involve hospital-acquired infections and post operative sepsis (overwhelming infection).

A Chicago Tribune study revealed that serious violations of infection-control standards have been found in the vast majority of hospitals nationally. Since 1995, more than 75 percent of all hospitals have been cited for significant cleanliness and sanitation violations. This report says:

A hidden epidemic of life-threatening infections is contaminating America’s hospitals, needlessly killing tens of thousands of patients each year. Nearly three-quarters of the deadly infections are preventable, the result of unsanitary facilities, germ-laden instruments, unwashed hands and other lapses.

Deaths linked to hospital germs represent the fourth leading cause of mortality among Americans, behind heart disease, cancer and strokes, according to the federal Centers for Disease Control and Prevention. These infections kill more people each year than car accidents, fires and drowning combined.

“The number of people needlessly killed by hospital infections is unbelievable, but the public doesn’t know anything about it,” said Dr. Barry Farr, a leading infection-control expert and president of the Society for Healthcare Epidemiology of America.

Dr. Berger’s Comment

When it comes to cleanliness and strict adherence to infection control procedures, there is no medical or surgical facility better than Chapel Hill Tubal Reversal Center. Our patients often comment about the meticulous nature of our facility. It is clean, orderly, and uncluttered. We are obsessive about this.

The idea that it may be safer to have elective surgery in a hospital is wrong. Hospitals are the right place for treating complicated medical or surgical problems, but they are not the best place for healthy people to have tubal reversal surgery!

Note

Dr. Berger was an Epidemic Intelligence Service Officer at the Centers for Disease Control (CDC).

I received an email message today from a patient that prompted me to write about informed consent for tubal ligation. (See my previous blog about informed consent for tubal reversal.) Here is the message that was sent to me.

Hello, Dr. Berger,

You performed tubal reversal surgery on me on 10/29/07, and I just found out that I’m pregnant. Thank you so much! This is such a blessing. I filled out the report and have heard back from Sarah Meacham. I’ll make sure to follow her instructions.

I’m writing because I have a friend named Samantha who wants to get reversal surgery, but she would like to make sure she’s a candidate based on the information in her operative report. I told her that I would send it to you so you can look it over, so it’s attached. She and her husband have two cute little girls, but she agreed to the tubal ligation on the operating table after she gave birth to her youngest at the prodding of her doctor. She said that she made a terrible mistake and wants more children. And like me, no one she’s asked in south Florida will even consider the procedure that you do. When I told her about you, she was ecstatic. And now that I’m pregnant, she knows that it works!

Thank you again for the miracles you work for so many women. God bless you and your staff!

Sincerely,
Amy P.

I was glad to hear that Amy was pregnant and had recommended to Samantha that she come here for her tubal reversal procedure, but this part of the message caught my attention:

“…she agreed to the tubal ligation on the operating table after she gave birth to her youngest at the prodding of her doctor. She said that she made a terrible mistake…”

What Is Informed Consent?

Before performing a tubal ligation – an elective operation – a doctor should always obtain the patient’s informed consent. Informed consent is the process through which the patient becomes educated about the procedure – including its benefits, risks and alternatives – and makes the decision to have the procedure performed. Informed consent implies that the patient fully understands the issues, has asked any questions she has, had her questions answered, and makes her decision under no duress. Adequate time should be allowed for a patient to think about all of the issues before consenting to the operation.

Should Consent For Tubal Ligation be Made During Childbirth?

Many tubal reversal patients have told me that the first time they discussed a tubal ligation with their doctor while they were on their way to the operating room for a C-section. Some regretted their decision while they were on the operating table or when they awoke in the recovery room. Other patients have said they had a tubal ligation in response to pressure from their spouse, parents, or their doctor. Labor and delivery is not the best time to think about an issue with such profound and lasting results as surgical sterilization. This should be discussed and thought about at leisure, not during the stress of childbirth.

Dr. Berger’s Comment

Besides the doctor’s responsibilities in obtaining informed consent, the patient also has a responsibility when giving it. A tubal ligation is not an emergency operation. Having a tubal ligation is a decision that should be carefully considered and not made in haste. There is adequate time during the pregnancy for a doctor and patient to discuss the issue of sterilization. Bringing this up for the first time on the way to the delivery room is a mistake, in my opinion. A more deliberate approach to the process of informed consent by both doctor and patient would help avoid mistaken decisions, such as in Samantha’s case.